<form action='{$base_uri}index.php/WidgetForm/Fillout/{$formId}' id="ajaxForm{$formId}" method="post">
{if $open}
<input type="button" onClick="formSubmit({$formId});" value="Update" />
{/if}
<input type="hidden" name="form_id" value="{$formId}" />
<input type="hidden" name="process" value="true" />
<input type="hidden" name="filloutType" value="encounter" />
<table>
	<tbody><tr>
		<td valign="middle">
		</td>
	</tr>
	<tr><td colspan="2">Chief Complaint: {input type="string" name="subjective_chief_complaint"  size="30"}</td></tr>
	<tr>
		<td colspan="2" valign="top">
			Comments: {input type="text" name="subjective_note" id="" rows="2" cols="70"}

		</td>
	</tr>
</tbody></table>
</form>
